ABG's, TB Chapter 2 NCLEX Test Questions
And Answers
As the nurse admits a patient in end-stage kidney disease to the
hospital, the patient tells the nurse, "If my heart or breathing stop, I
do not want to be resuscitated." Which action is best for the nurse
to take?
a. Ask if these wishes have been discussed with the health care
provider.
b. Place a "Do Not Resuscitate" (DNR) notation in the patient's care
plan.
c. Inform the patient that a notarized advance directive must be
included in the record or resuscitation must be performed.
d. Advise the patient to designate a person to make health care
decisions when the patient is not able to make them
independently. -
correct answer ✅A
A patient who was involved in a motor vehicle crash has had a
tracheostomy placed to allow for continued mechanical ventilation.
How should the nurse interpret the following arterial blood gas
results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25
mEq/L?
a. Metabolic acidosis
b. Metabolic alkalosis
,ABG's, TB Chapter 2 NCLEX Test Questions
And Answers
c. Respiratory acidosis
d. Respiratory alkalosis -
correct answer ✅ANS: D
The pH indicates that the patient has alkalosis and the low PaCO2
indicates a respiratory cause. The other responses are incorrect
based on the pH and the normal HCO3.
The nurse is caring for a patient with a massive burn injury and
possible hypovolemia. Which assessment data will be of most
concern to the nurse?
a. Blood pressure is 90/40 mm Hg.
b. Urine output is 30 mL over the last hour.
c. Oral fluid intake is 100 mL for the last 8 hours.
d. There is prolonged skin tenting over the sternum. -
correct answer ✅ANS: A
The blood pressure indicates that the patient may be developing
hypovolemic shock as a result of intravascular fluid loss due to the
burn injury. This finding will require immediate intervention to
prevent the complications associated with systemic hypoperfusion.
The poor oral intake, decreased urine output, and skin tenting all
indicate the need for increasing the patient's fluid intake but not as
urgently as the hypotension.
,ABG's, TB Chapter 2 NCLEX Test Questions
And Answers
The home health nurse cares for an alert and oriented older adult
patient with a history of dehydration. Which instructions should the
nurse give to this patient related to fluid intake?
a. "Increase fluids if your mouth feels dry.
b. "More fluids are needed if you feel thirsty."
c. "Drink more fluids in the late evening hours."
d. "If you feel lethargic or confused, you need more to drink." -
correct answer ✅ANS: A
An alert, older patient will be able to self-assess for signs of oral
dryness such as thick oral secretions or dry-appearing mucosa. The
thirst mechanism decreases with age and is not an accurate
indicator of volume depletion. Many older patients prefer to
restrict fluids slightly in the evening to improve sleep quality. The
patient will not be likely to notice and act appropriately when
changes in level of consciousness occur.
A patient who is taking a potassium-wasting diuretic for treatment
of hypertension complains of generalized weakness. It is most
appropriate for the nurse to take which action?
a. Assess for facial muscle spasms.
b. Ask the patient about loose stools.
, ABG's, TB Chapter 2 NCLEX Test Questions
And Answers
c. Suggest that the patient avoid orange juice with meals.
d. Ask the health care provider to order a basic metabolic panel. -
correct answer ✅ANS: D
Generalized weakness is a manifestation of hypokalemia. After the
health care provider orders the metabolic panel, the nurse should
check the potassium level. Facial muscle spasms might occur with
hypocalcemia. Orange juice is high in potassium and would be
advisable to drink if the patient was hypokalemic. Loose stools are
associated with hyperkalemia.
A newly admitted patient is diagnosed with hyponatremia. When
making room assignments, the charge nurse should take which
action?
a. Assign the patient to a room near the nurse's station.
b. Place the patient in a room nearest to the water fountain.
c. Place the patient on telemetry to monitor for peaked T waves.
d. Assign the patient to a semi-private room and place an order for
a low-salt diet. -
correct answer ✅ANS: A
The patient should be placed near the nurse's station if confused in
order for the staff to closely monitor the patient. To help improve
serum sodium levels, water intake is restricted. Therefore a
And Answers
As the nurse admits a patient in end-stage kidney disease to the
hospital, the patient tells the nurse, "If my heart or breathing stop, I
do not want to be resuscitated." Which action is best for the nurse
to take?
a. Ask if these wishes have been discussed with the health care
provider.
b. Place a "Do Not Resuscitate" (DNR) notation in the patient's care
plan.
c. Inform the patient that a notarized advance directive must be
included in the record or resuscitation must be performed.
d. Advise the patient to designate a person to make health care
decisions when the patient is not able to make them
independently. -
correct answer ✅A
A patient who was involved in a motor vehicle crash has had a
tracheostomy placed to allow for continued mechanical ventilation.
How should the nurse interpret the following arterial blood gas
results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25
mEq/L?
a. Metabolic acidosis
b. Metabolic alkalosis
,ABG's, TB Chapter 2 NCLEX Test Questions
And Answers
c. Respiratory acidosis
d. Respiratory alkalosis -
correct answer ✅ANS: D
The pH indicates that the patient has alkalosis and the low PaCO2
indicates a respiratory cause. The other responses are incorrect
based on the pH and the normal HCO3.
The nurse is caring for a patient with a massive burn injury and
possible hypovolemia. Which assessment data will be of most
concern to the nurse?
a. Blood pressure is 90/40 mm Hg.
b. Urine output is 30 mL over the last hour.
c. Oral fluid intake is 100 mL for the last 8 hours.
d. There is prolonged skin tenting over the sternum. -
correct answer ✅ANS: A
The blood pressure indicates that the patient may be developing
hypovolemic shock as a result of intravascular fluid loss due to the
burn injury. This finding will require immediate intervention to
prevent the complications associated with systemic hypoperfusion.
The poor oral intake, decreased urine output, and skin tenting all
indicate the need for increasing the patient's fluid intake but not as
urgently as the hypotension.
,ABG's, TB Chapter 2 NCLEX Test Questions
And Answers
The home health nurse cares for an alert and oriented older adult
patient with a history of dehydration. Which instructions should the
nurse give to this patient related to fluid intake?
a. "Increase fluids if your mouth feels dry.
b. "More fluids are needed if you feel thirsty."
c. "Drink more fluids in the late evening hours."
d. "If you feel lethargic or confused, you need more to drink." -
correct answer ✅ANS: A
An alert, older patient will be able to self-assess for signs of oral
dryness such as thick oral secretions or dry-appearing mucosa. The
thirst mechanism decreases with age and is not an accurate
indicator of volume depletion. Many older patients prefer to
restrict fluids slightly in the evening to improve sleep quality. The
patient will not be likely to notice and act appropriately when
changes in level of consciousness occur.
A patient who is taking a potassium-wasting diuretic for treatment
of hypertension complains of generalized weakness. It is most
appropriate for the nurse to take which action?
a. Assess for facial muscle spasms.
b. Ask the patient about loose stools.
, ABG's, TB Chapter 2 NCLEX Test Questions
And Answers
c. Suggest that the patient avoid orange juice with meals.
d. Ask the health care provider to order a basic metabolic panel. -
correct answer ✅ANS: D
Generalized weakness is a manifestation of hypokalemia. After the
health care provider orders the metabolic panel, the nurse should
check the potassium level. Facial muscle spasms might occur with
hypocalcemia. Orange juice is high in potassium and would be
advisable to drink if the patient was hypokalemic. Loose stools are
associated with hyperkalemia.
A newly admitted patient is diagnosed with hyponatremia. When
making room assignments, the charge nurse should take which
action?
a. Assign the patient to a room near the nurse's station.
b. Place the patient in a room nearest to the water fountain.
c. Place the patient on telemetry to monitor for peaked T waves.
d. Assign the patient to a semi-private room and place an order for
a low-salt diet. -
correct answer ✅ANS: A
The patient should be placed near the nurse's station if confused in
order for the staff to closely monitor the patient. To help improve
serum sodium levels, water intake is restricted. Therefore a
